Clinical Diagnosis and Case Analysis

ALL INFORMATION AND INTERVENTIONS ARE TO BE BASED ON A WESTERN PSYCHOLOGICAL APPROACH

ALL EVENTS TAKE PLACE IN BALTIMORE, MD USA.

BIO-PSYCHO-SOCIALSPIRITUAL ASSESSMENT OF CLIENT SYSTEM
Complete a Bio-Psycho-Social-Spiritual Assessment of Client System using the template outlined below.

Follow this template exactly:

THE CLIENTS NAME IS BEN AND HE LIVES IN BALTIMORE, MD USA

DESCRIPTION OF THE CLIENT SYSTEM:

      a) Client/Family Identifying Information

HE LIVES WITH HIS MOTHER AND HAS NO SIBLINGS

      b) Reason(s) for services
ANTISOCIAL BEHAVIOR AFTER THE MURDER OF HIS FATHER

      c)  Household Members (to include relationships with one on another, and their
              patterns of functioning)
MOTHER ONLY

      d)  Household Living Conditions

      e)  Financial History (to include all insurance information, excessive debt, etc.)

          MEDICAID INSURANCE

SOCIAL RELATIONSHIPS AND SUPPORTS

Family History: In this section, you will present data on family members (be sure to designate the members living in the household).  Names, gender, birth dates (or ages), relationships, marriage dates, education, occupations, deaths (causes), chronic conditions (e.g. alcoholism, mental retardation), significant trauma (e.g. fire, rape, incarceration), anything significant to describing individual. Other data that may be significant: adoptions, miscarriages, pregnancies, separations, current locations, etc.

    b)  Community System:  Describe relationships between client/family members and the
          various systems they are affiliated with or connected to. Describe community context
          and include a description of neighborhood resources.

    c)  Assets and Resources: Information about the clients informal sources of support. Information about the client primary and secondary sources of support. The type (what need does the source meet) and frequency (how often) of support from whom (e.g., friends, extended family members, church, etc.) provides support? Assess if the support provided is reliable.

SOCIAL HISTORY:

    a)  Physical Health (past and present, make certain to include any medication schedules, family history of medical condition

NO MEDICAL ISSUES

  b)  Mental Health: This section will include a brief history of family psychiatric problems. Report whether client has a history of psychiatric disorders; admission into mental health clinic (inpatient or outpatient), dates receiving services, the outcome of services, medication, treating therapist (past or present); family history or mental disorders. History of homicidal and suicidal ideation;

BIPOLAR DISORDER/ANTISOCIAL BEHAVIOR

    b)  Alcohol and Drug Use: Summarize if client used any substance in lifetime (e.g. cigarettes, marijuana, cocaine, etc.). Periods of sobriety and treatment (when, where and with whom); describe the outcome of treatment.

    c)  Sexual History: Describe sexual activity, sexual orientation, physical, sexual abuse (victim/offender). Explore if relevant to the problem situation. It is appropriate to assess if client practices safe sex and receives regular physical check-ups. If client reports being diagnosed with sexual disease, it is appropriate to explore, medication received, primary physician, etc.

SEXUAL ENCOUNTERS WERE NORMAL FOR A CHILD HIS AGE

    d)  Educational: Describe clients educational background, the highest level of degree attained. Difficulties in school (why, where, when); special education needs; suspensions. Include any informal educational skills. If client did not graduate from high school or received a GED, explore what barriers were present.

11TH GRADE EDUCATION-HOMESCHOOLED

    e)  Employment? Work History: Summarize clients type of work; attitudes toward work, reasons for leaving or being fired from previous jobs. Also, include any voluntary work (e.g. community, church, etc.). Make sure to include any military experience and informal employment.

NO EMPLOYMENT EXPERIENCE

    f) Recreational: Describe their activities or interest they enjoy, such as hobbies, sports, or leisure pursuits, special talents or skills. Are they involved in any church-related activities (e.g. bible school, bible camp)?

MUSIC, VIDEO GAMES, COMPUTERS, SOCIAL MEDIA

    g) Cultural Family Norms: Describe cultural beliefs; rituals, patterns. Do they have family reunions or times when they come together (outside of marriages and funerals?

    h)  Religious/Spiritual: Describe if client identifies with a particular religion or faith. Describe how client expresses spirituality. Describe clients current and past religious and spiritual practices. Describe if client is associated with a place of worship. Describe if their religion or spirituality is helpful to them.

BAPTIST RELIGION

      i)  Strengths and Competencies:  Describe client/family strengths, capacities, abilities, competencies and resources that may help to address and resolve the issues of concern.

RESILIENCE,

PRESENTING PROBLEM: Provide a concise clinical assessment of the presenting problem(s).  Student will complete a case formulation with preliminary diagnosis with justification as to why you selected these diagnoses.  Justification for the identified diagnoses should be included and identified within the case summary.
           
AGGRESSIVE BEHAVIORS, MARIJUANA USE

                      SUBSTANCE ABUSE AND BIPOLAR DISORDER

G3. Intervention Plan for Client System

Create a treatment plan to include goals and tasks to be completed. (Make certain that you include who will do what and when.)

Students should include 3 Long-term Goals with 2 Short term goals for each.  Students should use the S.M.A.R.T Goals approach with developing the treatment plan.

G4. Termination of Intervention with Client System

Describe the process and plan of a successful termination with the client system based on the EVIDENCE-BASED PRACTICE model utilized, ( i.e. follow-up sessions, rituals, etc.,) Be specific and make certain that you include feelings and reactions that the client might experience and explain how you would address the feelings based on the practice model implemented.

H. Plan for Evaluating Effectiveness of Practice with Client System.

Outline a plan for evaluating the effectiveness of your intervention including the following:
1) desired outcome(s) of intervention;
2) Measurement of outcomes;
3) Research approach used and rationale (quantitative, qualitative, or mixed-method);
3) Research design used and rationale (single system, quasi-experimental, etc.);
4) Process for collecting data on outcome measures;
5) Plan for analyzing data; and
6) How you will use the findings to improve your practice with this or similar clients in the future.

APPENDIX – References Include a reference page in APA 6th edition format citing all sources used (e.g., theorists, authors).

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